Post-stroke Fatigue and Depressive Symptoms Are Differentially Related to Mobility and Cognitive Performance

Gene Expression of Neurogenesis Related to Exercise Intensity in a Cerebral Infarction Rat Model

Regular exercise improves several functions, including cognition, in patients with stroke. However, the effect of regular exercise on neurogenesis related to cognition remains doubtful. We investigated the most effective exercise intensity for functional recovery after stroke using RNA sequencing following regular treadmill exercise. Photothrombotic cerebral infarction was conducted for 10-week-old male Sprague-Dawley rats (n = 36). A Morris water maze (MWM) test was performed before a regular treadmill exercise program (5 days/week, 4 weeks). Rats were randomly divided into four groups: group A (no exercise); group B (low intensity, maximal velocity 18 m/min); group C (moderate intensity, maximal velocity 24 m/min) and group D (high intensity, maximal velocity 30 m/min). After 4 weeks, another MWM test was performed, and all rats were sacrificed. RNA sequencing was performed with ipsilesional hippocampal tissue. On the day after cerebral infarction, no differences in escape latency and velocity were observed among the groups. At 4 weeks after cerebral infarction, the escape latencies in groups B, C, and D were shorter than in group A. The escape latencies in groups B and C were shorter than in group D. The velocity in groups A, B, and C was faster than in group D. Thirty gene symbols related to neurogenesis were detected (p < 0.05, fold change > 1.0, average normalized read count > four times). In the neurotrophin-signaling pathway, the CHK gene was upregulated, and the NF-κB gene was downregulated in the low-intensity group. The CHK and NF-κB genes were both downregulated in the moderate-intensity group. The Raf and IRAK genes were downregulated in the high-intensity group. Western blot analysis showed that NF-κB expression was lowest in the moderate-intensity group, whereas CHK and Raf were elevated, and IRAK was decreased in the high-intensity group. Moderate-intensity exercise may contribute to neuroplasticity. Variation in the expression of neurotrophins in neurogenesis according to exercise intensity may reveal the mechanism of neuroplasticity. Thus, NF-κB is the key neurotrophin for neurogenesis related to exercise intensity.

Improving physical movement during stroke rehabilitation: investigating associations between sleep measured by wearable actigraphy technology, fatigue, and key biomarkers

BACKGROUND

Sleep disturbance and fatigue are common in individuals undergoing inpatient rehabilitation following stroke. Understanding the relationships between sleep, fatigue, motor performance, and key biomarkers of inflammation and neuroplasticity could provide valuable insight into stroke recovery, possibly leading to personalized rehabilitation strategies. This study aimed to investigate the influence of sleep quality on motor function following stroke utilizing wearable technology to obtain objective sleep measurements. Additionally, we aimed to determine if there were relationships between sleep, fatigue, and motor function. Lastly, the study aimed to determine if salivary biomarkers of stress, inflammation, and neuroplasticity were associated with motor function or fatigue post-stroke.

METHODS

Eighteen individuals who experienced a stroke and were undergoing inpatient rehabilitation participated in a cross-sectional observational study. Following consent, participants completed questionnaires to assess sleep patterns, fatigue, and quality of life. Objective sleep was measured throughout one night using the wearable Philips Actiwatch. Upper limb motor performance was assessed on the following day and saliva was collected for biomarker analysis. Correlation analyses were performed to assess the relationships between variables.

RESULTS

Participants reported poor sleep quality, frequent awakenings, and difficulties falling asleep following stroke. We identified a significant negative relationship between fatigue severity and both sleep quality (r=-0.539, p = 0.021) and participants experience of awakening from sleep (r=-0.656, p = 0.003). A significant positive relationship was found between grip strength on the non-hemiplegic limb and salivary gene expression of Brain-derived Neurotrophic Factor (r = 0.606, p = 0.028), as well as a significant negative relationship between grip strength on the hemiplegic side and salivary gene expression of C-reactive Protein (r=-0.556, p = 0.048).

CONCLUSION

The findings of this study emphasize the importance of considering sleep quality, fatigue, and biomarkers in stroke rehabilitation to optimize recovery and that interventions may need to be tailored to the individual. Future longitudinal studies are required to explore these relationships over time. Integrating wearable technology for sleep and biomarker analysis can enhance monitoring and prediction of outcomes following stroke, ultimately improving rehabilitation strategies and patient outcomes.

Network analysis of neuropsychiatric, cognitive, and functional complications of stroke: implications for novel treatment targets

AIM

Recovery from stroke is adversely affected by neuropsychiatric complications, cognitive impairment, and functional disability. Better knowledge of their mutual relationships is required to inform effective interventions. Network theory enables the conceptualization of symptoms and impairments as dynamic and mutually interacting systems. We aimed to identify interactions of poststroke complications using network analysis in diverse stroke samples.

METHODS

Data from 2185 patients were sourced from member studies of STROKOG (Stroke and Cognition Consortium), an international collaboration of stroke studies. Networks were generated for each cohort, whereby nodes represented neuropsychiatric symptoms, cognitive deficits, and disabilities on activities of daily living. Edges characterized associations between them. Centrality measures were used to identify hub items.

RESULTS

Across cohorts, a single network of interrelated poststroke complications emerged. Networks exhibited dissociable depression, apathy, fatigue, cognitive impairment, and functional disability modules. Worry was the most central symptom across cohorts, irrespective of the depression scale used. Items relating to activities of daily living were also highly central nodes. Follow-up analysis in two studies revealed that individuals who worried had more densely connected networks than those free of worry (CASPER [Cognition and Affect after Stroke: Prospective Evaluation of Risks] study: S = 9.72, P = 0.038; SSS [Sydney Stroke Study]: S = 13.56, P = 0.069).

CONCLUSION

Neuropsychiatric symptoms are highly interconnected with cognitive deficits and functional disabilities resulting from stroke. Given their central position and high level of connectedness, worry and activities of daily living have the potential to drive multimorbidity and mutual reinforcement between domains of poststroke complications. Targeting these factors early after stroke may have benefits that extend to other complications, leading to better stroke outcomes.

Nourishing the Mind: How Food Security Influences Mental Wellbeing

Food insecurity is a significant public health problem worldwide and critical to mental health. There is a complex relationship between food security and mental health. We carried out a narrative review study aiming to address how food insecurity impacts mental wellbeing by focusing on the mental health repercussions of food insecurity, recognizing its pivotal role in attaining Sustainable Development Goals 2 (on hunger) and 3 (on enhancing global wellbeing). A comprehensive search was conducted on PubMed and Google Scholar, incorporating Google searches for pertinent reports and policy documents. To address these questions, we emphasized and elucidated the interconnectedness between food security and mental health. The review shows that food security and mental health share a profound relationship influenced by multifaceted factors like socioeconomic conditions, access to nutritious food, and societal inequalities. We then provide recommendations for integrating food security into mental health strategies based on the insights and conclusions drawn. Strategies ranging from sustainable farming practices to urban agriculture initiatives and digital mental health services demonstrate avenues for enhancing food safety and mental wellbeing. This highlights the need for collaborative interdisciplinary efforts and systemic reforms to address these interconnected challenges.

Prevalence of post-stroke cognitive impairment and associated risk factors in Chinese stroke survivors

BACKGROUND

Post-stroke cognitive impairment (PSCI) adversely affects survivors' recovery trajectory and overall health outcomes. This study aimed to investigate the prevalence of PCSI and its associated risk factors.

METHODS

A cross-sectional study was conducted with stroke survivors recruited from the neurology units of three hospitals in Yunnan, China. Measures included the Frenchay Aphasia Screening Test (FAST), Apathy Evaluation Scale (AES), Fatigue Severity Scale (FSS), Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE), Montreal Cognitive Assessment (MoCA), and Charlson Comorbidity Index (CCI). Logistic regression analysis was carried out to identify risk factors significantly and independently associated with PSCI.

RESULTS

Of 389 stroke participants studied, 139 (36%) were found to have PSCI. Every 10-year increase in age [odds ratio (OR) =1.69, 95% confidence interval (CI): 1.27-2.24, p < 0.001], and 1-point increase in the AES (OR = 1.13, 95% CI: 1.07-1.18, p < 0.001) and FSS scores (OR = 1.06, 95% CI: 1.03-1.10, p < 0.001) were significantly associated with higher odds of PSCI. Conversely, a 1-point increase in the MoCA score (OR = 0.91, 95% CI: 0.87-0.95, p < 0.001) and having an undergraduate education (OR = 0.45, 95% CI: 0.24-0.84, p = 0.013) or postgraduate education (OR = 0.18, 95% CI: 0.06-0.50, p = 0.001) were associated with reduced odds of PSCI.

CONCLUSIONS

PSCI is prevalent in the Chinese population, with advanced age, lower education levels, lower MoCA scores, and higher fatigue and apathy scores identified as strong risk factors. It is recommended that psychological and cognitive assessment be routinely incorporated into post-stroke rehabilitation pathways to mitigate cognitive decline.

Personalized Biomarkers and Neuropsychological Status Can Predict Post-Stroke Fatigue

Post-stroke fatigue (PSF) is a common complication of stroke that has a negative impact on prognosis and recovery. We aimed to investigate the relationship between PSF and demographics, mood disorders, sleep disorders, and other clinical characteristics of patients with stroke. In this exploratory cross-sectional study, we collected data on sociodemographic characteristics, biological indicators, and imaging features and evaluated patients using neuropsychological scales. Patients were assessed using the Fatigue Severity Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Scale, and Pittsburgh Sleep Quality Index. Magnetic resonance imaging scans were primarily used to evaluate infarctions and white matter lesions. The correlation between the PSF of patients with stroke and clinical indicators was obtained by logistic regression analysis and power analysis. We observed an independent association between fatigue severity and female sex (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.14-3.94), depressive state (OR, 1.50; 95% CI, 1.01-1.73), and sleep disorders (OR, 1.58; 95% CI, 1.01-1.98). High levels of blood glucose, serum uric acid, and homocysteine and low levels of serum triiodothyronine were strongly associated with poor functional outcomes in patients with stroke. Further studies are needed to elucidate how specific structural lesions and anxiety symptoms are related to early PSF.

Pressure Injury on Poststroke Admission Assessment to Skilled Nursing Facilities: Risk Factors, Management, and Impact on Rehabilitation

OBJECTIVE

To describe pressure injury (PrI) prevalence, comorbidities, and rehabilitation utilization among older adults with stroke at skilled nursing facilities' (SNFs') admission assessment.

DESIGN

Retrospective cohort.

SETTING AND PARTICIPANTS

Older Medicare beneficiaries (>65 years old) with stroke admitted to SNFs.

METHODS

We extracted data between 2013 and 2014 using the Master Beneficiary Summary, Medicare Provider Analysis and Review, and Minimum Data Set 3.0. PI data were assessed during admission assessment.

RESULTS

Of the 65,330 older adults poststroke admitted to SNFs, 11% had at least 1 PrI present on admission assessment. Individuals who were non-Hispanic Black, with a longer hospital stay, from lower socioeconomic status, with higher proportions of comorbidities (eg, underweight, urinary and bowel incontinence, diabetes, congestive heart failure, arrhythmias, and infections), and higher functional impairments were likely to present with a PrI at SNF admission assessment. Compared with individuals with superficial PrI, individuals with deep PrI were more likely to be young-old (<75 years), non-Hispanic Black, from lower socioeconomic status, present with a shorter hospital stay, an intensive care unit stay, with higher functional impairments, skin integrity issues, system failure, and infections. Compared to those without PrI or superficial PrI, individuals with any-stage PrI or deep PrI were more likely to be cotreated by physical and occupational therapist and less likely to receive individual therapy. Those with PrI poststroke had low documented turning and repositioning rates than those without PrI.

CONCLUSIONS AND IMPLICATIONS

Identifying modifiable risk factors to prevent PrIs poststroke in SNFs will facilitate targeted preventative interventions and improve wound care efficacy and rehabilitation utilization for optimized patient outcomes. Identifying residents with a higher risk of PrI during acute care discharge and providing early preventive care during post-acute care would possibly decrease costs and improve outcome quality.

The Effects of Vestibular Rehabilitation on Poststroke Fatigue: A Randomized Controlled Trial Study

Background

A major complication caused by stroke is poststroke fatigue (PSF), and by causing limitations in doing activities of daily living (ADL), it can lower the quality of life.

Objective

The present study is an attempt to examine the effects of vestibular rehabilitation on BADL (Basic Activities of Daily Living), fatigue, depression, and Lawton Instrumental Activities of Daily Living (IADL) in patients with stroke.

Method

Patients with a history of stroke took part voluntarily in a single-blind clinical trial. The participants were allocated to control and experimental groups randomly. The experimental group attended 24 sessions of vestibular rehabilitation protocol, while the control group received the standard rehabilitation (including three sessions per week each for around 60 min). To measure fatigue, the Fatigue Impact Scale (FIS) and the Fatigue Assessment Scale (FAS) were used. Depression, BADL, and IADL were measured using the Beck Depression Inventory-II (BDI-II), Barthel Index (BI), and Lawton Instrumental Activities of Daily Living, respectively. All changes were measured from the baseline after the intervention.

Results

Significant improvement was found in the experimental group compared to the control group (p < 0.05) in FIS (physical, cognition, and social subscales), FAS, BDI-II, BADL, and IADL. Moreover, the results showed small to medium and large effect sizes for the physical subscale of FIS and FAS scores based on Cohen's d, respectively; however, no significant difference was found in terms of cognition and social subscales of FIS, BDI-II, BADL, and IADL scores.

Conclusion

It is possible to improve fatigue, depression, and independence in BADL and IADL using vestibular rehabilitation. Thus, it is an effective intervention in case of stroke, which is also well tolerated.

Relevance of Cognition and Emotion for Patient-Reported Quality of Life After Stroke in Working Age: An Observational Cohort Study

Background

Patient-reported quality of life (QoL) may help to capture sequela of stroke more comprehensively. We aimed to investigate QoL in working age persons with ischemic stroke regarding impaired domains and identify factors associated with better QoL.

Methods

We invited persons with stroke aged 18–55 years to participate in this prospective observational study. We assessed QoL and self-rated health using the EuroQol 5 Dimension questionnaire (EQ-5D) during hospital stay (baseline) and at 3-months follow-up (FU). Additionally, the National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), cognition (Montreal Cognitive assessment, MOCA), emotion (Hospital Anxiety and Depression Scale), and return to work were evaluated. We used hierarchical regression to identify predictors of QoL (self-rated health and QoL Index score) at FU.

Results

We included 138 persons with stroke (mean age = 43.6 ± 10 years; 41% female; median admission NIHSS = 2), of whom 99 participated at FU. QoL Index and self-rated health were correlated with NIHSS, mRS, anxiety, and depression at both timepoints. Although 80% had favorable functional outcome at FU (mRS < 2), high proportions of these persons reported problems in the “Pain and/or Discomfort” (25.3%) and “Anxiety/Depression” (22.8%) dimensions. Only discharge NIHSS and baseline MOCA independently predicted self-rated health at FU. Female sex, higher discharge NIHSS, and higher baseline depression scores predicted worse QoL Index scores at FU.

Conclusions

Three months post-stroke, working age persons with stroke frequently reported problems in dimensions not assessed by the routinely used mRS. Despite correlations between clinical scales and QoL, patient-reported outcomes and screening for cognition and emotion ensure a more comprehensive assessment of post-stroke consequences relevant for QoL.

Serum Uric Acid Levels at Admission Could Predict the Chronic Post-stroke Fatigue

Background

Post-stroke fatigue (PSF) is a frequent complication of stroke. Serum uric acid (SUA) is frequently thought to be a risk factor for stroke. This study aimed to investigate whether SUA also played a role in PSF.

Methods

Subjects with ischemic stroke were screened from The First Affiliated Hospital of Wenzhou Medical University between January 2020 and October 2020. Patients' fatigue symptoms were assessed by the Fatigue severity scale (FSS). To investigate the relationship between SUA and PSF, binary logistic regression analysis was conducted, with the confounders being controlled. SUA levels were divided into four layers (Q1 ≤ 245 μmol/L; Q2 246–308 μmol/L; Q3 309–365 μmol/L; Q4 ≥366 μmol/L) based on the quartiles.

Results

SUA levels were significantly higher in the PSF group (345.96 ± 73.78 μmol/L) than the non-PSF group (295.97 ± 87.8 μmol/L, P < 0.001). There were no differences in any other variables between these two groups. After adjusting the confounders, the risk of PSF in the Q4 layer (≥366 μmol/L) was 6.05 times (95% CI 1.79–20.43, P = 0.004) higher than that in Q1 (≤245 μmol/L).

Conclusion

High SUA at admission was an independent risk factor for fatigue 1 year after stroke onset. High SUA (≥366 μmol/L) during stroke deserves more attention, and active control of high SUA levels may be beneficial to reduce the incidence of PSF in the chronic stage following stroke.

The Structural and Functional Neuroanatomy of Post-Stroke Depression and Executive Dysfunction: A Review of Neuroimaging Findings and Implications for Treatment

Post-stroke depression and executive dysfunction co-occur and are highly debilitating. Few treatments alleviate both depression and executive dysfunction after stroke. Understanding the brain network changes underlying post-stroke depression with executive dysfunction can inform the development of targeted and efficacious treatment. In this review, we synthesize neuroimaging findings in post-stroke depression and post-stroke executive dysfunction and highlight the network commonalities that may underlie this comorbidity. Structural and functional alterations in the cognitive control network, salience network, and default mode network are associated with depression and executive dysfunction after stroke. Specifically, post-stroke depression and executive dysfunction are both linked to changes in intrinsic functional connectivity within resting state networks, functional over-connectivity between the default mode and salience/cognitive control networks, and reduced cross-hemispheric frontoparietal functional connectivity. Cognitive training and noninvasive brain stimulation targeted at these brain network abnormalities and specific clinical phenotypes may help advance treatment for post-stroke depression with executive dysfunction.

A cross-sectional study exploring overlap in post-stroke fatigue caseness using three fatigue instruments: Fatigue Severity Scale, Fatigue Questionnaire and the Lynch's Clinical Interview

OBJECTIVE

Post stroke fatigue (PSF) is a frequent symptom affecting 25-73% of stroke survivors. The variability in estimates of prevalence found across studies reflects differences in fatigue measures and use of different cut-offs for defining clinically significant fatigue. The main aim of this study is to explore the frequency and overlap in caseness of fatigue using three different fatigue measures in a sample of patients at 3 months post stroke. Furthermore, we wanted to explore the instrument's associations with demographic and clinical characteristics.

METHODS

The sample consists of 93 patients with new onset stroke. This cross-sectional study includes three measurements of fatigue, The Fatigue Severity Scale (FSS), The Chalder Fatigue Questionnaire (FQ) and the Lynch Interview. Medical, physical, psychological data and estimates of pre-stroke fatigue were collected 3 months post stroke.

RESULTS

The FQ using the bimodal scoring yielded about 2.5 more fatigue cases (n = 57) than the FSS with a cut-off mean score of 5 (n = 22). The Lynch interview identified 48 patients as fatigue cases. Conducting multivariate analyses, the three instruments were differently associated with predictor variables such as prestroke fatigue, reduced balance and burden of symptoms reported post stroke.

CONCLUSION

The use of different instruments leads to a large variability in identifying fatigue cases in a sample of stroke patients. Scientifically and clinically a clarification and consensus on how to measure fatigue is warranted. Without correct identification of PSF-cases, knowledge about the causes of fatigue and development of tailored and interdisciplinary interventions are further delayed.

A randomized controlled trial to explore the efficacy and safety of transcranial direct current stimulation on patients with post-stroke fatigue

BACKGROUND

Post-stroke fatigue seriously affects the quality of life for stroke patients. There is no effective treatment at present. transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation which may have therapeutic effect on post-stroke fatigue. This study will explore about this.

METHOD

A total of 60 patients with post-stroke fatigue were randomly divided into the control group and the treatment group with 30 patients each by minimization randomization. Both groups received basic treatment and conventional rehabilitation. In the treatment group, patients were treated with active tDCS, while in the control group, sham tDCS. Both active and sham tDCS were administered 6 times a week for 4 weeks. Before and after the trial, the Fatigue Severity Scale (FSS), Fugl-Meyer Assessment (FMA) and Modified Barthel Index (MBI) were evaluated and analyzed. And comparisons were made among groups. And there were an 8-week follow-up after the intervention.

RESULT

Before the intervention, there were no significant differences in baseline data and assessment scores between the groups (P > 0.05). After 4 weeks of intervention, FSS scores in the treatment group were significantly lower than those in the control group (P = 0.012), and FMA and BMI scores were significantly higher than those in the control group (P < 0.05). There was no significant change in FSS scores after 8 months of follow-up (P > 0.05).

DISCUSSION

TDCS is a safe treatment that can effectively reduce the degree of fatigue after stroke, improve the motor function and daily activity ability of patients after stroke, and the efficacy is better than only routine rehabilitation training.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR2000031120. Registered on March 22, 2020.

Obesity and Poststroke Fatigue: A 2-Year Longitudinal Study

Introduction

Obesity is associated with fatigue in many diseases, but the correlation between obesity and poststroke fatigue (PSF) is unclear. The study aimed to investigate the relationship between body mass index (BMI) and the occurrence of and recovery from PSF.

Methods

Within 3 days of the onset of ischemic stroke, patients were consecutively recruited. We assessed PSF at admission and at 6, 12, and 24 months with the Fatigue Severity Scale (FSS). Multivariable logistic regression and restricted cubic spline function were used to explore the relationships between baseline BMI and the risk of PSF at different time points. The correlation between baseline BMI and the dynamic changes in the natural logarithm transformation of the FSS (lnFSS) score during the follow-up period was analyzed by the piecewise linear mixed-effects model.

Results

A total of 1026 stroke patients were included. Multivariable analyses indicated that obesity was associated with a decreased risk of early PSF (fatigue diagnosed at baseline) [odds ratio (OR) 0.61, 95% confidence interval (CI) 0.41–0.93] but an increased risk of late PSF (fatigue diagnosed 6 months after the index stroke) (OR 1.63, 95% CI 1.06–2.50 for 6 months; OR 1.87, 95% CI 1.18–2.96 for 12 months; OR 2.11, 95% CI 1.28–3.49 for 24 months). Longitudinal analyses indicated that in the late stage of fatigue, the higher the BMI category, the slower the rate of decrease was for the FSS score.

Conclusion

Obese patients are less likely to develop fatigue in the acute stage of ischemic stroke. However, they are more prone to late fatigue and exhibit a slower decline in the FSS score in the long term.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40120-021-00276-x.

An Exercise Mimetic Approach to Reduce Poststroke Deconditioning and Enhance Stroke Recovery

Evidence supports early rehabilitation after stroke to limit disability. However, stroke survivors are typically sedentary and experience significant cardiovascular and muscular deconditioning. Despite growing consensus that preclinical and clinical stroke recovery research should be aligned, there have been few attempts to incorporate cardiovascular and skeletal muscle deconditioning into animal models of stroke. Here, we demonstrate in rats that a hindlimb sensorimotor cortex stroke results in both cardiovascular and skeletal muscle deconditioning and impairments in gait akin to those observed in humans. To reduce poststroke behavioral, cardiovascular, and skeletal muscle perturbations, we then used a combinatorial intervention consisting of aerobic and resistance exercise in conjunction with administration of resveratrol (RESV), a drug with exercise mimetic properties. A combination of aerobic and resistance exercise mitigated decreases in cardiovascular fitness and attenuated skeletal muscle abnormalities. RESV, beginning 24 hours poststroke, reduced acute hindlimb impairments, improved recovery in hindlimb function, increased vascular density in the perilesional cortex, and attenuated skeletal muscle fiber changes. Early RESV treatment and aerobic and resistance exercise independently provided poststroke benefits, at a time when individuals are rapidly becoming deconditioned as a result of inactivity. Although no additive effects were observed in these experiments, this approach represents a promising strategy to reduce poststroke behavioral impairments and minimize deconditioning. As such, this treatment regime has potential for enabling patients to engage in more intensive rehabilitation at an earlier time following stroke when mechanisms of neuroplasticity are most prevalent.

Neuropsychiatric Complications after Stroke

Neuropsychiatric disturbances represent a common and uniquely challenging consequence of stroke. These disorders arise at the intersection of lesion-related brain dysfunction and psychological distress related to the event and its aftermath, making it difficult to identify what symptom is a direct physiological consequence of the stroke. Depression, anxiety, fatigue, apathy, emotionalism, and anger are the most common of these syndromes, and posttraumatic stress disorder related to the stroke event has become increasingly recognized as a relevant entity. Mania, obsessive-compulsive disorder, and psychosis are less commonly encountered but potentially highly debilitating conditions that may be underrecognized. Early identification and treatment may mitigate functional impairment and improve quality of life. Evidence-based guidelines from the general population are often relied upon to guide treatment. Further research is needed to understand and tailor treatment of these disorders in the poststroke population.

Canadian Platform for Trials in Noninvasive Brain Stimulation (CanStim) Consensus Recommendations for Repetitive Transcranial Magnetic Stimulation in Upper Extremity Motor Stroke Rehabilitation Trials

Objective. To develop consensus recommendations for the use of repetitive transcranial magnetic stimulation (rTMS) as an adjunct intervention for upper extremity motor recovery in stroke rehabilitation clinical trials. Participants. The Canadian Platform for Trials in Non-Invasive Brain Stimulation (CanStim) convened a multidisciplinary team of clinicians and researchers from institutions across Canada to form the CanStim Consensus Expert Working Group. Consensus Process. Four consensus themes were identified: (1) patient population, (2) rehabilitation interventions, (3) outcome measures, and (4) stimulation parameters. Theme leaders conducted comprehensive evidence reviews for each theme, and during a 2-day Consensus Meeting, the Expert Working Group used a weighted dot-voting consensus procedure to achieve consensus on recommendations for the use of rTMS as an adjunct intervention in motor stroke recovery rehabilitation clinical trials. Results. Based on best available evidence, consensus was achieved for recommendations identifying the target poststroke population, rehabilitation intervention, objective and subjective outcomes, and specific rTMS parameters for rehabilitation trials evaluating the efficacy of rTMS as an adjunct therapy for upper extremity motor stroke recovery. Conclusions. The establishment of the CanStim platform and development of these consensus recommendations is a first step toward the translation of noninvasive brain stimulation technologies from the laboratory to clinic to enhance stroke recovery.

Predictors and short-term outcomes of post-stroke fatigue in initial phase of transition from hospital to home: A prospective observational study

AIM

To analyse the interactions of associated factors with post stroke fatigue (PSF) after discharge home and determine the predictors of PSF and their impact on stroke survivors.

DESIGN

A prospective observational study.

METHODS

A total of 94 patients with acute stroke were recruited between May 2019 -July 2020. The main outcomes were fatigue, depression, insomnia, sarcopenia, and health-related quality of life (HRQOL) and were assessed at admission and 1 month after discharge. Fatigue was measured using the Fatigue Assessment Scale. Depression and Insomnia were assessed using the Hospital Anxiety and Depression Scale-Depression and Insomnia Severity Index, respectively. Sarcopenia was measured using the SARC-F questionnaire, and HRQOL was assessed using the Short Form-8.

RESULTS

Acute phase PSF was an independent predictor of PSF after discharge home. Moreover the path analysis revealed that this effect is mediated through both the direct effect of acute-phase PSF on PSF after discharge home and through the indirect effect of interaction with pre-stroke SARC-F, acute phase depression, and acute phase insomnia, which remains a separate predictor of acute-phase PSF. In total, 17% of the survivors had persistent PSF. Persistent PSF was significantly associated with depression, insomnia, sarcopenia, and a lower quality of life scores.

CONCLUSIONS

Post-stroke fatigue may occur in the acute phase and persists after discharge, it will not only affect later depression, insomnia, and quality of life, but also sarcopenia.

IMPACT

Acute phase PSF was found to be an independent predictor of PSF after discharge home. In addition, the interaction with pre-stroke SARC-F, acute phase depression and insomnia had an indirect connection with PSF after discharge home, which remains a separate predictor of acute-phase PSF. Thus, early assessment and management of mental status, sleep problems, and sarcopenia during hospitalization might be an important step in post-stroke rehabilitation and home transition.

Baseline white matter hyperintensities affect the course of cognitive function after small vessel disease-related stroke: a prospective observational study

Background and purpose

Cognitive impairment is a common sequel of recent small subcortical infarction (RSSI) and might be negatively affected by preexisting cerebral small vessel disease (SVD). We investigated whether the course of cognitive function in patients with RSSI is influenced by the severity of white matter hyperintensities (WMH), an important imaging feature of SVD.

Methods

Patients with magnetic resonance imaging (MRI)‐proven single RSSI were tested neuropsychologically concerning global cognition, processing speed, attention, and set‐shifting. Deep and periventricular WMH severity was assessed using the Fazekas scale, and total WMH lesion volume was calculated from T1‐weighted MRI images. We compared baseline function and course of cognition 15 months after the acute event in patients with absent, mild, and moderate‐to‐severe WMH.

Results

The study cohort comprised 82 RSSI patients (mean age: 61 ± 10 years, 23% female). At baseline, 40% had cognitive impairment (1.5 standard deviations below standardized mean), and deficits persisted in one‐third of the sample after 15 months. After age correction, there were no significant differences in set‐shifting between WMH groups at baseline. However, although patients without WMH (deep: p < 0.001, periventricular: p = 0.067) or only mild WMH (deep: p = 0.098, periventricular: p = 0.001) improved in set‐shifting after 15 months, there was no improvement in patients with moderate‐to‐severe WMH (deep: p = 0.980, periventricular: p = 0.816). Baseline total WMH volume (p = 0.002) was the only significant predictor for attention 15 months poststroke.

Conclusions

This longitudinal study demonstrates that preexisting moderate‐to‐severe WMH negatively affect the restoration of cognitive function after RSSI, suggesting limited functional reserve in patients with preexisting SVD.

Associations between Lesion Locations and Stroke Recurrence in Survivors of First-ever Ischemic Stroke: A Prospective Cohort Study

Several studies have indicated that stroke survivors with multiple lesions or with larger lesion volumes have a higher risk of stroke recurrence. However, the relationship between lesion locations and stroke recurrence is unclear. We conducted a prospective cohort study of first-ever ischemic stroke survivors who were consecutively enrolled from January 2010 to December 2015. Stroke recurrence was assessed every 3 months after post-discharge via telephone interviews by trained interviewers. Lesion locations were obtained from hospital-based MRI or CT scans and classified using two classification systems that were based on cerebral hemisphere or vascular territory and brain anatomical structures. Flexible parametric survival models using the proportional hazards scale (PH model) were used to analyze the time-to-event data. Among 633 survivors, 63.51% (n=402) had anterior circulation ischemia (ACI), and more than half of all ACIs occurred in the subcortex. After a median follow-up of 2.5 years, 117 (18.48%) survivors developed a recurrent stroke. The results of the multivariate PH model showed that survivors with non-brain lesions were at higher risk of recurrence than those with right-side lesions (HR, 2.79; 95%CI, 1.53, 5.08; P=0.001). There was no increase in risk among survivors with left-side lesions (HR, 0.97; 95%CI, 0.53, 1.75; P=0.914) or both-side lesions (HR, 1.24; 95%CI, 0.75, 2.07; P=0.401) compared to those with right-side lesions. Additionally, there were no associations between stroke recurrence and lesion locations that were classified based on vascular territory and brain anatomical structures. It was concluded that first-ever ischemic stroke survivors with non-brain lesion had higher recurrence risk than those with right-side lesion, although no significant associations were found when the lesion locations were classified by vascular territory and brain anatomical structures.

An integrative review: Challenges and opportunities for stroke survivors and caregivers in hospital to home transition care

AIM

To identify challenges and opportunities for stroke survivors and caregivers in hospital to home transition care.

BACKGROUND

Due to shortened hospital stays, stroke survivors and caregivers must take responsibility for complex care on discharge from hospital to home. Gaps exist in the literature that synthesizes studies on hospital to home transition care.

DESIGN

A systematic integrated review.

DATA SOURCES

Six databases were searched systematically between 18 June 2018 - 31 October 2018 including Medline, CINAHL, Web of Science, ProQuest, Scopus and Science Direct. The search did not have a date limit.

REVIEW METHODS

Studies that met the selection criteria were critically reviewed. Data were extracted from the studies for analyses. A convergent qualitative synthesis approach using inductive thematic synthesis was applied to the review.

RESULTS

The analysis of 23 studies identified three major findings. First, health and social care systems influence transition care by either enabling stroke survivors and caregivers to manage transition care via well-coordinated services or preventing them from accessing services. Second, health professionals' partnership with stroke survivors and caregivers largely decides tailored support for them. Successful partnerships and engagements with stroke survivors and caregivers depend on organizational resources. Third, survivors and caregivers are at different levels of readiness to cope with challenges. Individualized support for them to develop resilience is highly regarded.

CONCLUSION

Stroke survivors and caregivers encounter enormous challenges in self-management of hospital to home transition care. Further research is required to address their expectations of support during transition care.

IMPACT

There is a lack of synthesis of studies on factors affecting hospital to home transition care for stroke survivors. Health and social care system designs, health professionals' commitment to individualized care and the self-management capability of stroke survivors and their caregivers have a profound influence on the transition care experiences.

Poststroke Fatigue Is Related to Motor and Cognitive Performance: A Secondary Analysis

BACKGROUND AND PURPOSE

Poststroke fatigue (PSF) is a common debilitating and persistent symptom after stroke. The relationship between PSF and motor and cognitive function remains inconclusive partly due to lack of control for effects of depression and use of insensitive measures. We examined the relationship between PSF and motor and cognitive performance using a comprehensive set of behavioral measures and excluding individuals with depression.

METHODS

Fifty-three individuals poststroke (16 female) were included (median age: 63 years, median months poststroke: 20 months). Poststroke fatigue was quantified using the Fatigue Severity Scale (FSS) and cognitive performance was measured with the Montreal Cognitive Assessment, simple and choice reaction time (SRT and CRT) tasks. Lower extremity motor performance included Fugl-Meyer Motor Assessment, 5 times sit-to-stand test (5 × STS), Berg Balance Scale, Functional Ambulation Category, and gait speed. Upper extremity motor performance was indexed with Fugl-Meyer, grip strength, and Box and Block test. Spearman correlation and stepwise linear regression analyses were performed to examine relationships.

RESULTS

Two motor performance measures, Berg Balance Scale and Functional Ambulation Category, were significantly correlated with FSS (ρ = -0.31 and -0.27, respectively) while all cognitive measures were significantly correlated with FSS (ρ = -0.28 for Montreal Cognitive Assessment, 0.29 for SRT, and 0.29 for CRT). Regression analysis showed that Berg Balance Scale was the only significant determinant for FSS (R = 0.11).

DISCUSSION AND CONCLUSIONS

Functional gait, balance, and cognitive performance are associated with PSF. Fatigue should be considered when planning and delivering interventions for individuals with stroke. Future studies are needed to explore the potential efficacy of balance and cognitive training in PSF management.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A287).

Trajectories of fatigue among stroke patients from the acute phase to 18 months post-injury: A latent class analysis

Introduction

Post-stroke fatigue (PSF) is a common symptom affecting 23–75% of stroke survivors. It is associated with increased risk of institutionalization and death, and it is of many patients considered among the worst symptoms to cope with after stroke. Longitudinal studies focusing on trajectories of fatigue may contribute to understanding patients’ experience of fatigue over time and its associated factors, yet only a few have been conducted to date.

Objectives

To explore whether subgroups of stroke survivors with distinct trajectories of fatigue in the first 18 months post stroke could be identified and whether these subgroups differ regarding sociodemographic, medical and/or symptom-related characteristics.

Materials and methods

115 patients with first-ever stroke admitted to Oslo University Hospital or Buskerud Hospital were recruited and data was collected prospectively during the acute phase and at 6, 12 and 18 months post stroke. Data on fatigue (both pre- and post-stroke), sociodemographic, medical and symptom-related characteristics were collected through structured interviews, standardized questionnaires and from the patients’ medical records.

Growth mixture modeling (GMM) was used to identify latent classes, i.e., subgroups of patients, based on their Fatigue Severity Scales (FSS) scores at the four time points. Differences in sociodemographic, medical, and symptom-related characteristics between the latent classes were evaluated using univariate and multivariable ordinal regression analyses.

Results and their significance

Using GMM, three latent classes of fatigue trajectories over 18 months were identified, characterized by differing levels of fatigue: low, moderate and high. The mean FSS score for each class remained relatively stable across all four time points. In the univariate analyses, age <75, pre-stroke fatigue, multiple comorbidities, current depression, disturbed sleep and some ADL impairment were associated with higher fatigue trajectories. In the multivariable analyses, pre-stroke fatigue (OR 4.92, 95% CI 1.84–13.2), multiple comorbidities (OR 4,52,95% CI 1.85–11.1) and not working (OR 4.61, 95% CI 1.36–15,7) were the strongest predictor of higher fatigue trajectories The findings of this study may be helpful for clinicians in identifying patients at risk of developing chronic fatigue after stroke.

Post-stroke fatigue: a scoping review

Background: Post-stroke fatigue (PSF) is one of the most common and frustrating outcomes of stroke. It has a high prevalence and it can persist for many years after stroke. PSF itself contributes to a wider range of undesirable outcomes that affect all aspects of daily life. The aim of this review was to identify and summarise the most recent research on PSF, in order to update the evidence base. Methods: We updated an existing review (Hinkle et al. 2017) systematically searching CINAHL, MEDLINE, PsycINFO, and PubMed to cover new research studies between 1 st March 2016 and the search date (19 th January 2020). We included interventional and observational research, and clinical practice guidelines that were not covered in the original review. After duplicate removal in EndNote, two reviewers screened the search results in Rayyan, and data from eligible full texts were extracted onto an Excel spreadsheet. Finally, we used RobotReviewer and a human reviewer to assess the risk of bias of randomised trials for this scoping review. Results: We identified 45 records for 30 studies (14 observational, 10 interventional studies, and 6 guidelines). Apart from one, the interventional studies were single-centred, had high risk of bias and small sample size (median 50). They investigated exercise, pharmacotherapy, psychotherapy, education, and light therapy. Observational studies mainly reported the factors related to PSF including co-morbidities, depression and anxiety, quality of life, activities of daily living, stroke severity, medication use and polypharmacy, polymorphism, pain, apathy, limb heaviness, neuroticism, mobility, and thyroid-stimulating hormone. Guidelines either did not report on PSF or, when reported, their recommendations were supported by little or low level of evidence. Conclusion: Although we identified a number of recent studies which have added to our current knowledge on PSF, none are robust enough to change current clinical practice.

Post-stroke fatigue: a scoping review

Background: Post-stroke fatigue (PSF) is one of the most common and frustrating outcomes of stroke. It has a high prevalence and it can persist for many years after stroke. PSF itself contributes to a wider range of undesirable outcomes that affect all aspects of daily life. The aim of this review was to identify and summarise the most recent research on PSF, in order to update the evidence base. Methods: We updated an existing review (Hinkle et al. 2017) systematically searching CINAHL, MEDLINE, PsycINFO, and PubMed to cover new research studies between 1 st March 2016 and the search date (19 th January 2020). We included interventional and observational research, and clinical practice guidelines that were not covered in the original review. After duplicate removal in EndNote, two reviewers screened the search results in Rayyan, and data from eligible full texts were extracted onto an Excel spreadsheet. Finally, we used RobotReviewer and a human reviewer to assess the risk of bias of randomised trials for this scoping review. Results: We identified 45 records for 30 studies (14 observational, 10 interventional studies, and 6 guidelines). Apart from one, the interventional studies were single-centred, had high risk of bias and small sample size (median 50). They investigated exercise, pharmacotherapy, psychotherapy, education, and light therapy. Observational studies mainly reported the factors related to PSF including co-morbidities, depression and anxiety, quality of life, activities of daily living, stroke severity, medication use and polypharmacy, polymorphism, pain, apathy, limb heaviness, neuroticism, mobility, and thyroid-stimulating hormone. Guidelines either did not report on PSF or, when reported, their recommendations were supported by little or low level of evidence. Conclusion: Although we identified a number of recent studies which have added to our current knowledge on PSF, none are robust enough to change current clinical practice.

Domains of Functional Impairment and Their Associations with Thwarted Belonging and Perceived Burden in Older Adults

Objectives: Functional impairment and social disconnection are risk factors for suicide in later life. This paper examines associations between domains of functional impairment and two forms of social disconnection that are empirically linked to suicide in later life - low (or thwarted) belonging and perceived burden on others.Methods: Participants are 62 older primary care patients (67.68% female, mean age = 72.05) who endorsed feeling lonely or like a burden. Participants completed self-report measures of low belonging and perceived burden (INQ-R) and domains of functional impairment (WHODAS 2.0) at a single time point.Results: Greater perceived burden was associated with greater impairment in activities of daily living ("self-care"), while greater thwarted belonging was associated with greater impairment in social functioning, when controlling for depressive symptoms and age. Domains of mobility, cognition and social participation were not associated with either belonging or perceived burden.Conclusions: Impairment in self-care (ADLs) and social functioning may be more strongly associated with perceived burden and thwarted belonging than other domains of functional impairment.Clinical Implications: Considering specific domains of functional impairment - rather than functioning more broadly - may facilitate tailored interventions to target suicide risk.

Canadian Stroke Best Practice Recommendations: Mood, Cognition and Fatigue following Stroke, 6th edition update 2019

The 2019 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for Mood, Cognition and Fatigue following Stroke is a comprehensive set of evidence-based guidelines addressing three important issues that can negatively impact the lives of people who have had a stroke. These include post-stroke depression and anxiety, vascular cognitive impairment, and post-stroke fatigue. Following stroke, approximately 20% to 50% of all persons may be affected by at least one of these conditions. There may also be overlap between conditions, particularly fatigue and depression. If not recognized and treated in a timely matter, these conditions can lead to worse long-term outcomes. The theme of this edition of the CSBPR is Partnerships and Collaborations, which stresses the importance of integration and coordination across the healthcare system to ensure timely and seamless care to optimize recovery and outcomes. Accordingly, these recommendations place strong emphasis on the importance of timely screening and assessments, and timely and adequate initiation of treatment across care settings. Ideally, when screening is suggestive of a mood or cognition issue, patients and families should be referred for in-depth assessment by healthcare providers with expertise in these areas. As the complexity of patients treated for stroke increases, continuity of care and strong communication among healthcare professionals, and between members of the healthcare team and the patient and their family is an even bigger imperative, as stressed throughout the recommendations, as they are critical elements to ensure smooth transitions from acute care to active rehabilitation and reintegration into their community.

The Fatigue Assessment Scale: quality and availability in sarcoidosis and other diseases

PURPOSE OF REVIEW

Fatigue is a problem experienced by many patients suffering from chronic diseases, including sarcoidosis patients. It has a substantial influence on patients' quality of life (QoL). It is, therefore, important to properly assess fatigue with a valid and reliable measure. The Fatigue Assessment Scale (FAS) is the only validated self-reporting instrument classifying fatigue in sarcoidosis. The aim of this review was to examine the psychometric properties of the FAS and the diseases and languages in which it has been used. Studies among sarcoidosis patients were also reviewed in terms of outcomes.

RECENT FINDINGS

Studies were identified by searching the electronic bibliographic database Pubmed. Search terms used were: FAS and fatigue. Articles were included in the review if the FAS had been used to assess fatigue.

RESULTS

Since its introduction, the FAS was used in 26 different diseases or conditions, including stroke, neurologic disorders, rheumatoid arthritis, idiopathic pulmonary fibrosis and sarcoidosis. Its reliability and validity have proved to be good. Unidimensionality has been established. So far, the FAS is available in 20 languages and widely used in sarcoidosis. Digital versions as well as PDFs of various languages are available online (www.wasog.org).

SUMMARY

The FAS has good psychometric qualities for the diseases in which it has been examined, including sarcoidosis, and can be used in clinical practice. Healthcare workers can use the FAS to assess fatigue in the management, follow-up and clinical care programmes for their patients consistently across countries, as well as in clinical research.

[The prognosis for post-stroke aphasia]

AIM

To determine risk factors and factors of favorable prognosis for regression of post-stroke aphasia in the early recovery period of ischemic stroke (IS).

MATERIAL AND METHODS

A cohort study was undertaken with 40 patients with different clinical forms of aphasia. The duration of study was 3-4 months of the disease. The regression of speech and non-speech cognitive impairment was assessed by the Method of a 10-point evaluation of higher mental functions. The method involves a comprehensive assessment of all mental functions with more than 90 subtests at the beginning and at the end of rehabilitation course and the calculation of the difference in the scoring of each mental function as a measure of treatment efficacy. Using logistic regression and odds ratio estimation, significance of the influence and the prognostic relationship of symptoms related to IS, and a number of biological and social factors (sex, age, and education) were studied.

RESULTS

An independent prognostic value for the aphasia regression on the third month of disease has the severity of neurologic symptomatology (NIHSS score) for the first day of stroke (OR 3,27 95% CI 1,02-9,77) and the third month of the disease (p=0,005, OR 4,6, 95% CI [1,39-15,11]) and the decrease in daily activity assessed by the total score of the Barthel index (p=0,004, OR 3,92, 95% CI [1,01-15,21]). A number of MRI signs (localization of post-stroke changes in the left angular gyrus, frontal-temporal region and focal volume) had a significant effect on the dynamics of non-verbal cognitive impairment. Neuropsychological examination revealed a significant improvement of speech in patients with initially severe forms of aphasias, in particular, sensory and sensorimotor. A direct relationship between age and certain clinical forms of aphasia as well as a significant positive effect of duration (β=1,91, p≤0,01) and level of education (β=1,68, p≤0,007) on aphasia regression were determined.

CONCLUSION

The severity of neurologic symptoms, in particular motor and sensory deficits, both in the acute and in the recovery period of the disease is one of the pathogenetic factors worsening the processes of functional reorganization of neuronal speech networks. The positive dynamics of the recovery of speech function is associated with the initial severity and clinical form of aphasia. The level and duration of education are related to factors positively affecting post-stroke neuroplasticity.

Does depression after stroke negatively influence physical disability? A systematic review and meta-analysis of longitudinal studies

BACKGROUND

Depression after stroke is common and has been proposed to negatively affect disability by preventing optimal physical rehabilitation and recovery. However, the nature of this influence remains poorly understood. Here, we synthesise longitudinal studies to examine the hypotheses that depression after stroke (i) hampers physical rehabilitation, (ii) prevents functional improvement during recovery, and (iii) is associated with poor functional outcomes.

METHODS

A systematic literature search was conducted using the databases PubMed and Web of Science. A total of 5672 studies were screened; 28 met criteria for inclusion. The quality of included studies was assessed using the Newcastle-Ottawa Scale.

RESULTS

Individual studies showed no consistent effects of depression post-stroke on (i) the effectiveness of physical rehabilitation and (ii) functional improvements during recovery. In contrast, random-effects models revealed that (iii) depression after stroke was associated with an increased risk for poor long-term disability (OR: 2.16, 95% CI 1.70-2.77). Overall, the quality of studies was moderate and there was evidence for publication bias.

LIMITATIONS

The number of included studies was small. There was considerable methodological heterogeneity between studies, prohibiting meta-analyses for all effects of interest. Few studies examined the influence of antidepressants.

CONCLUSIONS

Depressed stroke patients are generally more disabled. However, depressed mood might not restrict improvements in physical disability during rehabilitation and recovery, although it seems to be linked to a delayed increase in the risk of poor functional outcome. High-quality evidence from longitudinal studies is needed to clarify the precise mechanisms and temporal dynamics underlying these associations.

Prolyl hydroxylase domain inhibitors: can multiple mechanisms be an opportunity for ischemic stroke?

Stroke and cerebrovascular disease are now the fifth most common cause of death behind other diseases such as heart, cancer and respiratory disease and accounts for approximately 40-50 fatalities per 100,000 people each year in the United States. Currently the only therapy for acute stroke, is intravenous administration of tissue plasminogen activator which was approved in 1996 by the FDA. Surprisingly no new treatments have come on the market since, although endovascular mechanical thrombectomy is showing promising results in trials. Recently focus has shifted towards a preventative therapy rather than trying to reverse or limit the amount of damage occurring following stroke onset. During one of the components of ischemia, hypoxia, a number of physiological changes occur within neurons which include the stabilization of hypoxia-inducible factors. The activity of these proteins is regulated by O₂, Fe²⁺, 2-OG and ascorbate-dependant hydroxylases which contain prolyl-4-hydroxylase domains (PHDs). PHD inhibitors are capable of pharmacologically activating the body's own endogenous adaptive response to low levels of oxygen and have therefore become an attractive therapeutic target for treating ischemia. They have been widely used in the periphery and have been shown to have a preconditioning and protective effect against a later and more severe ischemic insult. Currently there are a number of these agents in phase 1, 2 and 3 clinical trials for the treatment of anemia. In this review we assess the neuroprotective effects of PHD inhibitors, including dimethyloxalylglycine and deferoxamine and suggest that not all of their effects in the CNS are HIF-dependent. Unravelling new roles and a better understanding of the function of PHD inhibitors in the CNS may be of great benefit especially when investigating their use in the treatment of stroke and other ischemic diseases.

Combined Cognitive-Motor Rehabilitation in Virtual Reality Improves Motor Outcomes in Chronic Stroke - A Pilot Study

Stroke is one of the most common causes of acquired disability, leaving numerous adults with cognitive and motor impairments, and affecting patients' capability to live independently. Virtual Reality (VR) based methods for stroke rehabilitation have mainly focused on motor rehabilitation but there is increasing interest toward the integration of cognitive training for providing more effective solutions. Here we investigate the feasibility for stroke recovery of a virtual cognitive-motor task, the Reh@Task, which combines adapted arm reaching, and attention and memory training. 24 participants in the chronic stage of stroke, with cognitive and motor deficits, were allocated to one of two groups (VR, Control). Both groups were enrolled in conventional occupational therapy, which mostly involves motor training. Additionally, the VR group underwent training with the Reh@Task and the control group performed time-matched conventional occupational therapy. Motor and cognitive competences were assessed at baseline, end of treatment (1 month) and at a 1-month follow-up through the Montreal Cognitive Assessment, Single Letter Cancelation, Digit Cancelation, Bells Test, Fugl-Meyer Assessment Test, Chedoke Arm and Hand Activity Inventory, Modified Ashworth Scale, and Barthel Index. Our results show that both groups improved in motor function over time, but the Reh@Task group displayed significantly higher between-group outcomes in the arm subpart of the Fugl-Meyer Assessment Test. Improvements in cognitive function were significant and similar in both groups. Overall, these results are supportive of the viability of VR tools that combine motor and cognitive training, such as the Reh@Task. Trial Registration: This trial was not registered because it is a small clinical study that addresses the feasibility of a prototype device.